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Recovery Auditor Prepayment Review Demo Still Pending

James Carroll, for HealthLeaders Media, July 12, 2012

Other staff members to consider when ramping up efforts against prepayment reviews are clinical documentation improvement nurses and professionals. In some cases, patients come in with more than one condition, so assigning the correct DRG becomes imperative, so these CDI nurses and  professionals should—in addition to staying up to date on CMS guidance related to the program—be involved in the process of concurrent review as well.

In addition, coders should be educated and confirm the order and patient type prior to billing, suggests Easterling.

Though it may surprise no one to hear it, providers need to make sure that medical records are as complete as possible before they go out the door. Make sure that the records do not have any signature issues, make sure that they have been pre-reviewed, and make sure that they contain all the necessary documentation; as these are the most important aspects of the record, explains Easterling.

In addition, she says, if providers see denials come into their facility as a result of these prepayment reviews, they should look into appealing that determination.

"Appeal, appeal, appeal. When you read that [the recent CMS update that came out on appeals], you tend to think that providers aren't appealing enough," she says. "Continue to appeal and work on documentation efforts."

For more information on the prepayment review demonstration program, click here.


James Carroll is associate editor for the HCPro Revenue Cycle Institute.
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